11 June 2007
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
Sir, I feel very helpless because nobody can help me without you. I u will send me mail, I shall be very thankful to you.
-Ali
Dear Ali: At 20 years of age you are no longer a boy. You are a man and have probably finished growing in which case there is no medicine which will make you grow more. Even though most of your relatives are tall, there may be some short relatives, and you may have inherited the genes to be short. Your height is still normal for a man. In fact, you are taller than me. I know it is hard to give up your ideas about being tall. If your relatives are tall you have spent all your life anticipating growing up to be as tall as they are, but there is nothing abnormal about being 5 foot 7 inches tall. It's time to stop worrying about it and focus your energy on more important things.
Sincerely,
Dr. Warren
-Stephen
Dear Stephen: Puberty and hormones do not generally aggravate eczema; however increased sweating and the need for increased showering might. Make sure you are using a moisturizing soap such as Dove soap. If your skin is very dry you might try Cetaphil Cleanser instead of soap. Make sure you moisturize after bathing.
There are no creams which can cure eczema, but there are many treatments which can help. You should consult your doctor or a dermatologist to start on treatment
Sincerely,
Dr. Warren
Thanks.
Please answer this ASAP.
Love,
-Rebecca
Dear Rebecca: A lot depends on the nature of your visit to the doctor. Most physicians recognize the need to respect a teenager's right to privacy. Without that, few teens would tell their pediatricians about certain problems. As a result, many states have laws which protect a teenager's right to privacy on matters of reproduction (sexual activity). I don't know the law in your state.
When you go to your doctor for a check up he should ask to conduct the exam without your parents in the room. On the other hand, if you go to the doctor for a sexually transmitted disease, it may be difficult for him to treat you without telling your parents anything. Most physicians will try to deal with it in the best way possible, but honestly, when you have a problem, there comes a point when you need to trust your parents enough to have your best interest at heart.
Contrary to the belief of many teens, a physician cannot tell simply by looking at a girl if she is a virgin. The hymenal ring can break from many non-sexual activities. Any physician who concluded that a girl was sexually active just because her hymen was not intact would be wrong. And any physician who felt obliged to share such findings with a parent for no reason other than it's what he found would not be providing the best care for his patient.
Given your concerns, you should ask your doctor what his policy is on privacy. Patient privacy and confidentiality is a cornerstone of the practice of medicine. This applies to kids as well as adults. Few physicians would want to violate that confidentiality unless they believed it would be in the child's best interest for a parent to be informed about something, in which case most physicians would limit the violation of the patient's privacy as much as possible and facilitate the discussion between parent and child to help resolve any resulting problems. In my own practice, if I felt a need to discuss something with a parent, I would work out the details and come to an agreement with my patient first.
Sincerely,
Dr. Warren
Sincerely,
-Susan
Dear Susan: Unfortunately, I have no information about nursing. I might suggest that you try About.com and see if they do. They have specialists in many areas.
One thing I can tell you is that a good general nursing education is an excellent preparation for pediatric nursing. There is no health profession which is more about providing care than nursing, and giving good care is so important in pediatrics. The rest will come by studying your texts about the diseases unique to pediatrics and from your experience caring for patients. Every health professional wants to know everything there is to know before dealing with patients, but there is simply no substitute for experience. Since nurses have the closest contact with the patients they quickly develop the skills of observation necessary to care for their patients. At first, you will depend on your more experienced colleagues to help you hone your skills. And one day you'll find that you're the one everyone is depending on.
Sincerely,
Dr. Warren
-SS
Dear SS: An acceleration of growth could certainly be a sign of precocious puberty, but not in the absence of other signs of puberty. Menstruation doesn't just suddenly appear. Pubertal development occurs in an orderly fashion. In girls that means you first see breast development, then pubic hair, and then menstruation. If your daughter has any breast development and pubic hair, even if it is not a lot, she should have a complete evaluation by a pediatric endocrinologist. If there are no signs of puberty, her interest in her genitals, her body odor and her large size are unrelated and do not indicate anything. In fact, you stated that the odor has been a problem since she was 2. If it was related to pubertal development by now there should have been more evidence of abnormal development.
Consider consulting a dermatologist about treatment with a topical antibiotic as sometimes bacteria on the skin may be responsible for unusual body odor.
Sincerely,
Dr. Warren
Thank you for your time.
-CT
Dear CT: Malessezia furfur is the name of the fungus which causes tinea versicolor. Tinea versicolor is a superficial fungus infection of the skin whose main symptom is an undesirable appearance. It can be treated with Lotrimin or Selsun shampoo. There is a high risk of recurrence in those who are prone to this infection. If it remains problematic you should consult a dermatologist.
Sincerely,
Dr. Warren
-AM
Dear AM: The child who is overly dependent on her bottle may very well have no appetite for food because she fills up on milk. The milk will meet her basic nutrition needs, but, indeed, she should start to eat a more adult diet in order to meet all her nutritional needs. The problem is, that in order for her to have an appetite for food, you have to cut down on her bottles. Most especially, you must insist that she take her bottle at one sitting rather than allowing her to have a continuous drip of milk into her stomach by sucking her bottle all day (which, by the way, is very bad for the teeth).
Cutting down on bottles or eliminating them is no easy task when a child is very attached to her bottle. First it provides the child comfort and it's tough for Mom to ignore her child's cries when she knows what will bring instant relief. Second, if the child is not eating, it provides Mom some security in that at least she knows the child is getting nourished from her bottle, but this is a false security since it is usually the bottle which is preventing the child from eating.
Before you attempt to make any change, review your daughter's health and growth with her pediatrician to be sure that she has been growing well and has not suffered any nutritional inadequacy. When you cut down on bottles you will not instantly see your daughter start eating. She will need to get used to the change first. Then, eliminate some of the bottles, and be sure that the ones given are consumed at one sitting. For advice on feeding read my article, Nutrition Without Tears.
Sincerely,
Dr. Warren
My Eldest Daughter is 7 years old. On 25th September she complained of fever, throat pain and a mild toe ache. I treated her with Brufen and Panadol and after 4 days she recovered but was weak aftter that. Intermittanly for the coming 2 weeks she kept on complaining of left toe pain but I regarded it as being due to her school shoes but neverthe less was uneasy in the mind. On the 10th of October she again develoed fever(upto 101) throat pain and the same toe ache. I took her to my paediatrician friend who ordered a few tests CP, ESR, ASOT , C Reactive Protein, Throat swab. She put her on Wymox 250 mg x 8 hourly. My daughter tested positive for CRP and her ASOT titres were also raised >200 <400 . Her ESR though is 5 Total and differential leucocytes are well within normal ranges. Her Hb is 12.5 gms. RBCs, platelets are all normal except for mild anisocytosis.
The paediatrician almost confirmed her diagnosis on these grounds and put her on Aspirin TDS. On 12th I took her to an emminent cardiologist who is the Head and Professor at a leading Government hospital out here(Islamabad). He conducted an Echo and EKG on her. The Echo and EKG were normal except one thing that the ECHO showed a mild MITRAL VALVE PROLAPSE of the anterior leaflet which the doctor reported as being Grade 1. There is no mitral regirgitation though. For some reason the cardiologist did not even comment on it and I only found out only later on reading the report myself. His opinion was that as he could not find any of the Major criteria of the disease he could not pronounce her as a case of RF. He disregarded the toe pain as being arthralgia and not Arthritis . Her toe is not inflamed or swollen and it is not tender to touch. Infact it is quite mobile. She complains of pain only when SHE HERSELF flexes or extends it.The cardiologist asked me to continue with Wymox but to discontinue Aspirin.He even allowed her to attend school from Monday. I took her to another experienced child specialist on Saturday and he too seemed to agree with the cardiologist. Both thought that raised ASOT and CRP were not conclusive evidences. My daughter was alright till sunday, when she returned from School however on Monday she again started complaining of toe pain. Since yesterday she is suffering from Abdominal discomfort and some sort of constrictive feeling in the throat. Yesterday she was quite lethargic and slept for some time in the afternoon too when normally she is active and playful at that time. She is still on Wymox. The child specialist had put her on Ferradol(a vitaminised Malt extractwith Iron) . I discontinued that since yesterday as her teeth were beginning to get stained. Now Iam at my wits end as to what to do.What could she ave. What are the abdominal symptoms due to . Can it all be something very minor and is all coincidentally co occuring. Can you help?? By the way her throat swab is negative too.
Waiting anxiously for your response. Thanks
-Dr. AS
Dear Dr. AS: The diagnosis of rheumatic fever is a clinical diagnosis which is made with the help of laboratory tests. Of particular importance is that there must be evidence of a preceding group A streptococcal infection; however, that alone even with joint pain and an elevated CRP is not enough to make the diagnosis. The diagnosis is still made by the Jones Criteria:
Major manifestationsThe diagnosis of rheumatic fever requires evidence of an antecedent streptococcal infection plus at least one major and two minor, or two major manifestations from the Jones criteria.Minor manifestations
- Carditis
- Polyarthritis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
- Arthralgias
- Fever
- Increased erythrocyte sedimentation rate or c-reactive protein
- Prolonged PR interval
I'm in agreement that your daughter has no major criteria. With no inflammation of the toe it is only arthralgia, not arthritis. The joints with rheumatic fever are swollen, red, and exquisitely tender, not just mildly sore. And the arthritis is described as a polyarthritis. Your daughter's joint pain has remained confined to one toe. Also of interest is that your daughter's symptoms occurred on two separate occasions, both associated with a sore throat. The average latent period between pharyngitis and rheumatic fever is 18 days, but the period ranges from 1 to 5 weeks. While streptococcal pharyngitis is the cause of rheumatic fever, the diagnosis is not generally made while the child has the pharyngitis. The fever, which did not persist with the toe pain, was most likely part of two separate acute illnesses rather than a minor criterion for diagnosing rheumatic fever. In addition, the negative throat culture is most consistent with a virus infection which can explain all your daughter's miseries.
If your daughter remains ill, with persistent symptoms, her doctor needs to take a fresh look at her. At this time, further consideration of rheumatic fever as a cause should be eliminated since she does not meet the criteria for that diagnosis. Continued consideration of this possibility may be distracting you and her doctor from objectively and appropriately assessing her current situation.
Sincerely,
Dr. Warren
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